Characteristics of mental health literacy measurement in youth: a scoping review of school-based surveys

Mental health literacy (MHL) was introduced 25 years ago as knowledge and beliefs about mental disorders which aid in their recognition, management, or prevention. This scoping review mapped the peer-reviewed literature to assess characteristics of secondary school-based surveys in school-attending youth and explore components of school-based programs for fostering MHL in this population. The search was performed following the method for scoping reviews by the Joanna Briggs Institute (JBI). Searches were conducted in four scientific databases with no time limit, although all sources had to be written in English. Primary studies (N = 44) provided insight into MHL surveys and programs for school-attending youth across 6 continents. Studies reported that most youth experience moderate or low MHL prior to program participation. School-based MHL programs are relatively unified in their definition and measures of MHL, using closed-ended scales, vignettes, or a combination of the two to measure youth MHL. However, before developing additional interventions, steps should be taken to address areas of weakness in current programming, such as the lack of a standardized tool for assessing MHL levels. Future research could assess the feasibility of developing and implementing a standard measurement protocol, with educator perspectives on integrating MHL efforts into the classroom. Identifying the base levels of MHL amongst school-attending youth promotes the development of targeted programs and reviewing the alignment with program components would allow researchers to build on what works, alter what does not, and come away with new ways to approach these complex challenges, ultimately advancing knowledge of MHL and improving levels of MHL.


Introduction
The concept of mental health literacy (MHL), originally defined by Jorm and colleagues [43] as "knowledge and beliefs about mental disorders which aid their recognition, management, or prevention" (p.182), was developed to consider people's level of knowledge of mental health [29].It is believed that there is a relationship between one's level of knowledge and understanding of mental health disorders and their likelihood to seek help.As such, identifying levels of MHL size.Counter to the MHL benefits experienced by students, Yamaguchi and colleagues [116] found that educators completing MHL training in preparation for providing school-based programming made broad claims about improvements in their MHL, only to have the improvements found to be of relatively low quality upon further evaluation.This finding is key as MHL programs and resources targeted toward educators and administrators are the foundation upon which school-based MHL programs are built.Gilham et al. [31] found that surveys of teachers' MHL tend to rely on the definition and measures developed by Jorm et al. [43], though the definition by Kutcher et al. [49,50] was used in one fourth of the papers reviewed.This finding relevant to educator surveys has not yet been assessed in surveys on students.

Programs to increase MHL in school settings
Most school-based MHL programs rely on the domino effect initiated by educators completing MHL training-building their own mental health literacy in order to successfully incorporate it into their existing lesson plans.Programs like Headstrong [80], Teen Mental Health First Aid [36,37], and the Mental Health and High School Curriculum Guide ("The Guide") [52] all take an educator-led approach to programming.The Guide is a popular Canadian example of educator-led school-based MHL programming that has shown a positive impact on youth MHL.Initially targeting educators, the ultimate goal of The Guide is to increase MHL in both educators and youth students through routine adaptations to the curriculum, which normalizes the inclusion and discussion of mental health concerns.To date, program evaluations have found significant improvement in youth student MHL following engagement with The Guide [70].The generally positive results of program evaluations for school-based MHL programs have been repeatedly challenged.A previous systematic review found that all evaluations reviewed suffered from at least a moderate risk for bias, with 63% of evaluations at high risk of bias [112].In addition, two more recent systematic reviews found that the current evidence for the implementation of school-based MHL interventions appears to be methodologically and psychometrically lax [78,93], demanding increased rigour and regularity of program evaluation for school-based MHL programs-a need that is magnified by the current return to school settings following the recent global COVID-19 pandemic.

Rationale
As pandemic-related school disruptions recede, youth and educators return to the classroom to re-establish the routines and necessary roles of in-person learning.The integration of MHL into the school environment continues to be an essential part of supporting youth through the trauma of the pandemic, cultivating skills that will carry them through future challenges.Recent scoping reviews have assessed the impact of school-based interventions on youth MHL that is specific to peer-led designs [47], the implementation processes related to school-based mental health services [87], school-based efforts to support youth who specifically cope with a history of trauma [99], and an analysis of the quality of recently-developed school-based MHL interventions [60].However, to the best of our knowledge, there are no scoping reviews describing the level of documented MHL of school-attending youth and characterizing components of current and previous school-based programs in depth.In order to establish depth of knowledge, we employ a more detailed analysis of school-based MHL interventions by extracting study conceptualization (e.g., MHL definition) in addition to details pertaining to the program and study design.Unique to this scoping review is the description of evidence of effectiveness of the school-based MHL programs, allowing the present review to gather a wide breadth of evidence pertaining to these programs, reporting on the key findings, outcomes, and effectiveness of the programs under investigation.
Our research questions are: (1) What characterizes mental health literacy surveys in school-attending youth?and (2) What are the components of school-based programs to foster MHL in youth?

Methods
This scoping review was conducted in accordance with the JBI methodology for scoping reviews [81].Scoping reviews address an exploratory research question by systematically searching, selecting, and synthesizing a wide range of literature to determine the breadth of evidence on a particular topic [81].They are a type of knowledge synthesis that scopes or maps a body of literature with relevance to time, location, source, method, and origin [54].
• bibliography (e.g., author and year of publication, country) • conceptualization (e.g., purpose of study, definition and citation used for defining MHL) • design (e.g., scale used to measure MHL, study design) • sample (e.g., size, sex, socioeconomic status, student type, school type), and • results (e.g., level of MHL in students, key findings of surveys).Data extracted from included papers is presented in a tabular form, Table 1 reports key findings relevant to the review question.Data was synthesized based on conceptualization and measurement of school-based MHL programs, which were then classified into themes using content analysis.Results were categorized by research questions.A narrative summary accompanies the tabulated data to describe how the results relate to the research question.

Characteristics of mental health literacy surveys in school-attending youth
Interest in youth MHL has grown steadily over the last 20 years, only to surge since 2019 with 45% of the publications reviewed here being published since 2019 (N = 20).Globally, Oceanic countries (N = 15; 34%) and European countries (N = 11; 25%) dominate the literature followed closely by North American (N = 9; 20%) and Asian countries (N = 8; 18%).In contrast, South American countries entered the dialogue with a single publication in 2021 (N = 1; 2%).

Conceptualization of MHL
Alongside this growth, Jorm and colleagues [43] appear to have established the accepted definition of MHL ("knowledge and beliefs about mental disorders which aid their recognition, management and prevention") capturing 50% (N = 22) of the citations in this review.Jorm and colleagues went on to produce variations of the predominant definition in 2000, 2006, and 2012, which account for 27% (N = 12) of the MHL definitions in the present review.Of the remaining MHL definitions, 18% remained unspecified (N = 8), while Wei et al. [112] and Kutcher et al. [49] were each cited once (5%).
Vol Across the 27 articles3 that empirically measured youth MHL, it was clearly identified which MHL component was being measured in 16 articles (59%).In the remaining articles, the measured components were identified based on the vocabulary used by the authors to describe their outcome measure (e.g., identify) and how it corresponded to the different MHL component descriptions.The component "recognition" refers to the capacity to identify signs and symptoms of a mental health disorder, "help-seeking" refers to knowing how, when, and where to get help, "knowledge" refers to the understanding of the different mental health disorders, and "stigma/attitudes" refers to the perception held by people with regards to mental health disorders [8,49].The most commonly measured component was "recognition" (N = 15; 56%), followed by "help-seeking" (N = 13; 48%), "stigma"/"attitudes" (N = 8; 30%), and "knowledge" (N = 5; 19%).The Friend in Need Questionnaire [11] was the most commonly used (N = 5; 19%) questionnaire to measure "recognition" and "help-seeking."

Examining gender differences in youth MHL
Amongst studies that assessed differences in MHL by sex (N = 15), 53% found that females experienced higher MHL than their male counterparts (N = 8) while the remaining 47% found no difference between the sexes (N = 7).

Common components of school-based programs to foster MHL in youth
Across this review, 39% (N = 17) of the studies provided an assessment of school-based MHL programs, evaluating the effectiveness of 15 unique MHL interventions-characteristics of which are outlined in Table 3-with more than half being written after 2018 (N = 12; 71%).In line with the broader findings of the review, most evaluations were based in Europe (N = 6; 35%), closely followed by North America (N = 5; 29%), Oceania (N = 4; 24%), and Asia (N = 2; 12%) and the bulk referenced a version of Jorm et al. 's [43] definition of MHL (can refer to publication years 2006, 2000, and/or 2012; N = 10; 59%).Of the remaining studies nearly, a quarter did not specify a definition of MHL (N = 5; 29%) and Wei et al. [112] and Kutcher et al. [49] were each cited once (6.25% each).Evaluations overwhelmingly took place in secondary/ high school classrooms (N = 12; 63%) with the remaining evaluations taking place in an unspecified location (N = 3; 16%) or middle schools (N = 3; 16%).
Only 53% of the assessed articles on MHL programs described the format of their programs.Out of those nine articles, it was found that the majority of the programs were classroom-based (N = 5), while the remaining programs were either school-based (N = 3), or curriculum-based (N = 2).One program was delivered in a voluntary fashion. 4he delivery of the programs varied across all programs in terms of duration.The training was often offered over the course of days N = 1 (1 day); N = 1 (3 day) or over multiple shorter sessions (N = 10).The number of sessions could vary between two to twenty-one, with the average ranging between three and six sessions.Three programs did not mention the duration of their training. Vol:.(1234567890)

Barriers and facilitators
Only one program failed to identify program barriers and facilitators.The program barriers mainly fell under the themes of (1) lack of educator training/support, (2) limitation in tools and measures, (3) flexibility of program (e.g., too flexible, difficulty targeting specific topics), and (4) school calendar and class schedule interfered with program delivery.On the other hand, the program facilitators mainly fell into the themes of (1) reviewed materials, making them "off-the-shelf" use, (2) positive feedback and dissemination of knowledge, (3) free web-based programming/materials, and (4) flexibility allowed for adaptability.

Discussion
The purpose of this review was to both scope the current MHL of school-attending youth and examine the components of current school-based programs targeting this population.We aimed to identify details related to the selected study designs and to the methodological quality of the school-based MHL interventions (i.e., key findings, outcomes, and effectiveness of the programs under investigation).

Characteristics of mental health literacy surveys in school-attending youth
With the majority of the articles on MHL being published in Oceanic and European countries, it appears as though Westernised countries have been most productive in generating outputs from MHL research on the student population.This is also true for community MHL surveys [39].On the other hand, developing countries (i.e., African and South American countries) are not as active in the scholarly discourse of student MHL.This contrast points to a lack of diversity in terms of observations and studies.In a previous review on MHL, it was proposed that more developed countries have greater MHL levels than less developed countries [28,29].These findings highlight what seems to be an absence of MHL in developing countries, potentially suggesting that the results are subject to mainstream western ideas.When looking at the widely accepted definition of mental disorders in the Western world, we see a definition reading "a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress, or disability or with significantly increased risk of suffering, death, pain, disability or an important loss of freedom" [4].Although this definition is used to diagnose mental health disorders in developed countries, it does not include the differing beliefs of various cultures associated with this concept.Indeed, countries such as Nigeria reject the idea that mental suffering is a health disorder [2].Many African countries include the notion of subjective experiences when explaining "mental disorders" which differs from the objective point of view of westernised countries.Within this argument, we can consider that MHL research may be less prominent in developing countries as their views on mental health differ from the traditional western idea of the concept, potentially making it harder to assess MHL.

Definition of MHL
The predominance of Jorm and colleagues [43] definition of MHL within our review presents some limitations to the assessment of MHL in youth.The Canadian Alliance on Mental Illness and Mental Health (2007) report critiqued Jorm's

Review
Discover Mental Health (2024) 4:24 | https://doi.org/10.1007/s44192-024-00079-0original MHL conceptualization as omitting facets of MHL knowledge and beliefs that constitute targets for positive mental health promotion in schools.This position resonates, given that none of the surveys reviewed measured all elements of the most comprehensive definition of MHL [40] with a consistent measure.This has also been found in a review of community [39] and educator surveys [31].This gap in research and practice indicates it may be challenging to measure all elements of MHL in a single study.As aforementioned, the contemporary version of MHL includes components such as help-seeking attitudes, knowledge of mental health resources, proactive maintenance of good mental health, and awareness of stigmatising attitudes and beliefs [40,49].Studies that fail to assess these additional elements of MHL, may overlook important barriers to youth help-seeking as well as facilitators for good mental health promotion and prevention for youth populations in education.Our results show that the most frequently evaluated components of MHL in youth are recognition and help-seeking.Although this is a step in the right direction with regards to having a more complete notion of youth MHL, it would be important to evaluate the remaining components as much to assure effective youth MHL programs.

Study design and sampling
The majority of the studies relied on a cross-sectional study design.Considering this type of design is one that allows to collect data at one specific occurrence [13], it has value in measuring baseline MHL.None of the program studies relied on a cross-sectional study, giving certain value to their results as the effects of the program were measured in some form throughout the program and not only at one time point (having baseline data on MHL helps elucidate any program effects).The age range of the studied population varied between the ages of 8 and 25-year-olds across the included articles.The majority of the studies used a sample of students aged between 10 and 25-years-old.According to Cloutier and team's paper [21], the studied sample can either be found in the concrete operational stage or the formal operational stage; it is not until the formal operational stage (starting at the age of 12) that an individual is deemed able to think abstractly.As such, students under the age of 12 may have greater difficulty understanding the abstract aspects of mental health disorders and thus render their MHL levels lower.Future studies on the topic should be conducted on a more specific and condensed age group to assure the reliability of the results.

Measurement of MHL
Measures for baseline MHL level varied considerably, with the most common measure used being [11] the Friends in Need Questionnaire (2006; N = 8; 17%).The Friends in Need Questionnaire employs a vignette method which asks youth respondents to read and comment on what they think is wrong with a fictitious youth.Vignette measures have been commonly used in MHL research as a means of assessing knowledge, beliefs and attitudes of mental health disorders [43].In the context of youth populations, and particularly for the purpose of assessing "help-seeking efficacy", which has been cited in contemporary definitions as an important facet of MHL [49], the use of this vignette paradigm presents some limitations.A youth respondent commenting on the pathology presentations depicted through a vignette may be akin to their observations of classmates and the identification of behaviours indicative of emerging mental health disorders in others.However, assessing this observational capacity alone ignores the respondents own insight and their ability to reflect on the state of their own mental health and wellbeing.Studies that seek to accurately assess elements of MHL that might predict help-seeking in youth, or improvements in helpseeking in response to MHL programming, should utilize measures that assess multiple facets of MHL, beyond those captured in the Friends in Need Questionnaire [11].

Gender differences and MHL
Across the majority of articles that assessed differences in MHL level in terms of sex, survey results showed that females reported greater levels of MHL than their male counterparts.Research suggests that females experience higher levels of mental health disorders [94], which may indicate that familiarity with mental illness contributes to MHL.Indeed, When analysing the discrepancies between mental health diagnoses across genders, female teenagers tend to experience (2024) 4:24 | https://doi.org/10.1007/s44192-024-00079-0Review internalising disorders such as anxiety more often than male teenagers [107].In turn, in a study on the effects of gender on MHL levels for anxiety disorders amongst teenagers, it was found that females had an overall greater MHL level than their male counterparts [34].Therefore, females who are exposed to mental illness via peer networks may hold less stigma toward mental illness and therefore have higher MHL.Considering this, future studies could look into the cause of this difference in MHL levels across genders.The findings may align with our hypothesis and as such, MHL programs may need to be formatted in a way that targets teenage males and attends to their specific lower MHL levels.

Components of school-based programs to foster MHL in youth
Overall, the majority of the school-based programs aimed to improve teenage students' knowledge on mental health disorders and bolster their notion of interventions and available support.The program delivery varied across the programs, but they were mostly educator-led, classroom-based, and delivered over multiple sessions.Amongst the reviewed MHL programs, all but one explicitly reported effectiveness in MHL outcomes.However, none of the programs relied on the same design or delivery method.Of course, the majority were primarily led by educators, class-based, and training was given over the course of several sessions; however, none appeared to use the same numbers of sessions or methods.In addition to the differing types of programs, it was found that none of the studies used the same evaluation methods to investigate the strength of their program or relied on the same sample size.Having inconsistent protocol evaluations and sample sizes brings to question whether or not the same results would be obtained if the same methods would be used.
As one program relied on the use of mental health experts to inform the program, it seems contradictory that one of the main identified program barriers was a lack of educator training or support and that one of the main identified program facilitators was accessible materials.Since MHL is a topic associated with mental health, one would assume that any efforts made to improve it would be based on knowledge translated by experts in the field.However, it appears that only one program in this review relied on said experts.This finding points to the importance of questioning the validity of the material used in the reviewed programs and further encourages future researchers to look into the efficacy of programs that rely or don't rely on material provided by experts in the field of mental health.Furthermore, it is intriguing how educators who were actively involved in program design, felt a lack of support, but also appeared to be satisfied with the facility they experienced to find material.Considering the contrasting perspectives of level of support, it may be important to pay attention to the effectiveness of the results and further investigate whether better mental health expert support would yield higher levels of MHL among students.Interestingly, a previous review on educator MHL by Gilham et al. [31] found that educators generally had low levels of MHL themselves.This further suggests that teachers may actually be ill-equipped to educate in-school youth on MHL and that the use of a valid way of measuring levels of MHL is necessary in order to truly identify levels of MHL.In line with these contradictory claims, the remainder of the identified barriers and facilitators are opposites (i.e., (1) flexibility of programs: either it makes it hard to target specific programs or it allows for adaptability; (2) materials: either hard to find or free online material).
When reviewing these results, all programs report some positive outcomes.To continue to identify 'what works' for school-based MHL programming, funding for research on MHL programs for youth should be increased so that long-term evaluation of mental health programs for youth can be performed.The long-term evaluations will enable assessment of the sustainability of these reported positive outcomes.

Limitations and future directions
This review was limited by the search strategy.Our search strategy was developed to identify all peer-reviewed literature that empirically measured MHL in youth students via surveys and any other methods of assessing MHL (e.g., teacher informant report) were not included.Thus, our findings are based on evidence garnered from school-based surveys of MHL and may not be applicable to the general population.

Review
Discover Mental Health (2024) 4:24 | https://doi.org/10.1007/s44192-024-00079-0 None of the articles reviewed measured all elements of the most comprehensive definition of MHL [40] with a consistent measure, suggesting that it may be challenging to measure all elements of MHL in a single study.Thus, while we are unable to identify levels of MHL in youth, we are able to highlight this gap in research and practice.
Future research on school-based MHL surveys should assess and report factors that influence individual's ability to become mental health literate that can help enable appropriate design of surveys (i.e., measuring determinants of, as well as level of, MHL) which can in turn, inform future implementation of MHL interventions and programs in school settings.For example, international students from newcomer families may conceptualize MHL in a linguistically and/or culturally specific way.Finally, a synthesis of MHL levels across different student characteristics (e.g., grade level, school type, experience with health curriculum that could influence literacy) would improve generalizability and add breadth to the current evidence base.

Conclusion
In the present study, we aimed to identify what characterizes mental health literacy surveys in school-attending youth and to uncover the components of school-based programs that foster MHL.Our review showed that most school-attending youth have moderate baseline levels of MHL, with females experiencing higher levels than their male counterparts.School-based MHL programs are relatively unified in their definition and measures of MHL, using closed-ended scales, vignettes, or a combination of the two to measure youth MHL.This research should in turn generate information that can be used to create policies in the educational system to implement MHL education in the curriculum.As seen in this scoping review, the majority of the programs in place have yielded improved MHL levels amongst their participants.Providing access to MHL education to the youth through school curriculums would provide them with improved knowledge and recognition for mental health disorders and hopefully reduce potential stigma and thus encourage help-seeking.Accordingly, this could reduce the current rates of mental health disorders amongst our youth and in turn improve their quality of life and reduce the demand on the health and psychological services that struggle to offer services.
To address limitations of the field, a key task will be to develop a standardized tool for assessing MHL levels for youth.Identifying the base levels of MHL amongst school-attending youth promotes the development of targeted programs and reviewing the alignment with program components would allow researchers to build on what works, alter what does not, and come away with new ways to approach these complex challenges, ultimately advancing knowledge of MHL and improving levels of MHL

Table 1
Inclusion and exclusion criteria for review of school-attending youth MHL [90]r search strategy and screening process focused on grade level (secondary school) rather than specific age of the students.Consequently, one study was included which suggests that the end of adolescence is not always defined[90]to capture the full extent of adolescence b One study that measured MHL in youth attending both elementary and secondary school was included to capture the secondary school results Criterion

Table 3
Characteristics of (N = 17) unique school-based mental health literacy programs for students Article

Table 3
Two programs, the Mental Health for Everyone program and the MEST, are based on notions of positive psychology.